CEN20LA078

NTSB accident investigation · Navion Navion · Fort Smith, AR · February 9, 2020

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
February 9, 2020, 15:00 local (21:00 UTC)
Place
Fort Smith, AR
Injuries
1 serious, 3 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1011MNavion Navion
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20200209002719A
Case key
100928

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The inadequate inspection of the fuel selector valve, which was degraded, allowed fuel to leak, and resulted in fuel starvation and a loss of engine power.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Damaged/degradedNavion NAVION G: 1 caseAll aircraft: 176 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect service/maintenanceNavion NAVION G: 1 caseAll aircraft: 176 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelNavion NAVION G: 3 casesAll aircraft: 320 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

Shortly after the pilot took off for a personal cross-country flight, about 300 ft above ground level, the engine lost partial power. The pilot lowered the airplane nose and the engine continued to operate, before losing total power. The pilot activated the electric fuel boost pump and engine power resumed for a few seconds. The pilot executed a forced landing to a grass area on airport property. During the forced landing, the airplane sustained substantial damage to both wings and the fuselage. Postaccident examination of the airplane revealed blue staining on and around the fuel selector valve area, consistent with a degraded valve. The valve failed leak checks during multiple vacuum tests to check external and internal leakage, which were called for in the manufacturer’s service bulletin 106 A and related airworthiness directive (AD) 2008-05-14. No fuel was found in any fuel lines or components from the firewall forward to the engine fuel components, and about 20 gallons of fuel was recovered from the airplane fuel tanks. It is likely the degraded fuel selector valve was leaking air, which resulted in fuel starvation to the engine. Aircraft records showed that the airplane and fuel selector valve were inspected and returned to service 2 days and about 18 flight hours before the accident. Based on the amount of fuel staining on and around the fuel selector valve and air leakage noted during the tests, the valve had likely become degraded before the last inspection. Given the valve’s degraded condition, it should have been tested and repaired or replaced during the last inspection in compliance with AD 2008-05-14.

Factual narrative

On February 9, 2020, about 1500 central standard time, a Navion G airplane, N1011M, impacted terrain during a forced landing near Fort Smith, Arkansas. The pilot, and two passengers sustained minor injuries, one passenger sustained serious injuries, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, shortly after takeoff about 300 ft above ground level, the engine lost partial power. The pilot lowered the airplane nose and the engine continued to operate. Shortly thereafter, the engine lost total power. The pilot activated the electric fuel boost pump and engine power resumed; however, the engine lost power again within a few seconds. The pilot executed a forced landing to a grass area on airport property. During the forced landing, the airplane impacted terrain and sustained substantial damage to both wings and the fuselage. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector and a mechanic revealed that the fuel selector valve exhibited blue staining on and around the fuel selector valve area. The fuel selector valve was removed for further examination. No fuel was found in any fuel lines or components from the firewall forward to the engine. About 20 gallons of fuel were removed from the airplane fuel tanks during recovery. A review of the aircraft records showed that an annual inspection was completed and airworthiness directive (AD) 2008-05-14, an inspection of the airplane fuel system, was complied with on February 7, 2020, at a total tachometer time of 224.25 hours. The airplane had accumulated 18.2 hours since the inspections. The FAA inspector examined the fuel selector valve and performed vacuum tests on the valve, in accordance with Navion Service Bulletin (SB) No. 106 A, Fuel System - Inspection of the fuel system continued safe operation. Visual examination of the fuel selector valve showed blue staining, consistent with fuel, near the valve stem and inside the airplane were the fuel selector valve was mounted. Multiple vacuum tests, performed to check external and internal leakage, failed the required leak checks per the SB. The AD referred directly to the SB and stated that the fuel selector valve should be repaired or replaced if it failed the tests.

Aircraft

Registration
N1011M
Reported as
Navion Navion (G)
Category
Airplane
Serial number
NAV-4-2470
Built
1962
Airframe hours
3,877
Engine
Continental IO-550N2, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 7, 2020
Departed
FSM · Fort Smith, AR
Destination
FSM · Fort Smith, AR
Airport
FSM · Fort Smith Regional Airport
Equipment
ADS-B, Handheld GPS

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Injuries
Minor
Certificates
Flight instructor, Commercial, Private
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 28, 2019
Seat
Left
Restraint
Lap only
Flight hours
3,302 total · 18 in this make and model · 3,091 as pilot in command · 74 in the last 90 days · 35 in the last 30 days · 18 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 10 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft overcast

Docket · 4

The files NTSB released with the investigation on March 25, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.2 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1011M · 1

Matched to the same aircraft by N-number and date.